Esther Parks

Myrnaivette Pierson Focus Note
Subjective:
Date of encounter: April 15, 2019

Patient Name or initials: Esther Park
Informant: 78-year-old woman, reliable historian
Chief Complaint: “I have some pain in my belly and I’m having trouble going to the
bathroom.”
History of present illness: Ms. Parks reports her pain started as a general discomfort
about five days ago. She states the pain is low and left in her belly. It is a crampy feeling
and 6 out of 10 pain. Patient states the pain is constant but gets worse when she moves
around a lot and when she eats. Patient states that she has tried taking small sips of warm
water but it did not help. She has not taken any medication for the pain. Patient states
that she became bloated three days ago and the pain worsened. This was followed by
several bouts of diarrhea, course of one day. Since then she has had no bowel movement.
She usually has a regular bowel movement every day but does occasionally miss one day.
She had to miss her exercise class because she was too weak. This is unusual for her. She
is normally very active with gardening, exercise class, water aerobics, and Pilates.
Allergies:
 Latex causes contact dermatitis
 Denies food or environmental allergies
Immunizations:
 All immunizations are current
 No influenza vaccination this season
Medications:
 Prescription
Accupril, 10 mg PO daily for HTN
 OTC Supplements
None reported
 Herbal Supplements
None reported
Past Medial History:
 Hypertension: diagnosed at age 54
Past Surgical History:
 Cholecystectomy at age 42
 C-section at age 40
 Reports hospitalizations for surgeries due to childbirth
Family History:
 Father: deceased at age 82, hx of HTN, hypercholesterolemia
 Mother: deceased at age 88, hx of HTN and DM type II
 Maternal Grandparents, hx of coronary artery disease, DM type II
 Paternal Grandparents, hx of obesity, CVA, HTN
 Brother, age 80 hx of HTN, hypercholesterolemia, prostate cancer
 Brother, age 81 hx of HTN
 Son, age 48 healthy
 Daughter, age 46 healthy
Personal and Social History:

 No past or present tobacco use
 Reports drinking 1 alcoholic drinks (white wine) per week
 Denies use of marijuana, cocaine, heroin or other illicit drugs
 Sexually active with one partner
Pertinent Review of systems:

General Survey
 Patient points to LLQ to identify discomfort
 Grimacing noted on movement
HEENT
 Denies sore throat
 Denies difficulty chewing or swallowing
Thorax and Lungs
 Denies shortness of breath
Cardiovascular
 Reports history of hypertension
 Denies chest pain
Gastrointestinal
 Constipation 5 days, normally bowel movement pattern every day, may miss a
day now and then
 Diarrhea came on suddenly, lasting one day. A few bouts of it over the course of
the day
 Bloating with pain started getting worse after digestive upset
 Denies indigestion, heartburn, vomiting or nausea
 Denies rectal bleeding
 Denies history of intestinal problems or GERD
 Denies traveling
Urinary
 Reports urine has been darker in color lately
 Urinating less often
 Denies pain during urination
Genital
 Denies vaginal discharge
 Denies pain
SUBJECTIVE REFLECTION:
Ms. Parks was easy to talk to and her responses were quick and concise. It may have
been helpful to ask for more details surrounding her cholecystectomy at age 42 including
complications that she may have experienced at the time. Although many years have
passed since her surgery, cholecystectomy can be related to constipation. A second
question to ask would be the date of her last sigmoidoscopy and the results of that exam.
A recent sigmoidoscopy could help to rule out intestinal obstruction and diverticulitis. A
third question would be about feeling recent stress of depression. These feelings can
cause physical symptoms similarly to the patient.
Objective:
Vital Signs:
 B/P: 110/70
 O2 Sat: 99%
 Pulse: 92
 RR: 16
 Temp: 370 C (oral)
 Height: 5 ft 2 in
 Weight: 120 lbs
 BMI: 21.9
Physical Exam:
Constitutional/General survey
 Uncomfortable and slightly flushed appearing, gray haired, elderly Asian woman,
AAOx3. Noticed grimace at times. Appears stable but mildly distressed.
HEENT
 Head/Face: slight flushing of cheeks
 Nose: right and left nostrils moist and pink
 Mouth/Throat: moist and pink
 Skin: warm and dry, no tenting
Cardiovascular
 S1, S2, no murmurs, gallops or rubs, regular rate and rhythm
 No S3, S4, no rubs. No lower extremity edema
Thorax and Lungs
 Vesicular breath sounds throughout
Gastrointestinal
 Asymmetric due to localized distention in LLQ
 Surgical scars in RUQ and midline in suprapubic region
 Normoactive bowel sounds in all quadrants
 No bruits noted to abdominal aorta, renal, iliac or femoral arteries
 No friction sounds over liver or spleen
 Tympany over RUQ, RLQ, LUQ. Dullness over LLQ
 Soft in all quadrants. An oblong mass (2 x 4 cm) noted in the LLQ with guarding,
distention
 No organomegaly, no CVA tenderness
 Liver span 7 cm in right midclavicular line, edge smooth, palpable 1 cm below right
costal margin
 Rectal exam found no hemorrhoids, fissures or ulcerations, strong sphincter tone,
fecal mass detected in rectal vault
Urinary:
 Bladder not palpable, no distention or tenderness
 Urinalysis: color is clear, dark yellow; normal odor; no nitrates, no WBCs, no
RBCs, no ketones, pH 6.5 (acidic), specific gravity 1.017
Genital:
 Pelvic exam; no inflammation or irritation of vulva, no abnormal discharge or
bleeding. No masses, no growths no tenderness upon palpation
OBJECTIVE REFLECTION:
There is no mention of a recent colonoscopy. Although age 75 is upper age limit,
this exam is pertinent to the patient’s HPI and should be recommended. Ms. Parks is a
vibrant, physically active and sexually active woman. Even though her age is outside the
recommendations for certain tests, her lifestyle makes the following tests a consideration.
There is also no mention of her being ever being tested for Hep C. Although Ms. Park
does not fall within CDC age recommendations (54-74) for Hep C testing it should be
considered. There is no mention of recent gynecological exam. Ms. Parks is sexually
intimate and a routine exam should be recommended.
Assessment:
Diagnosis:
Constipation – abdominal discomfort in LLQ, lack of regular bowel
movement for more than three days, fecal mass detected in rectal vault
Differential Diagnoses:
 Diverticulitis – Presenting with pain to LLQ, altered bowel habits, tender
colon, no fever
 Intestinal obstruction – rule out by CT scan or colonoscopy. (Do not order
barium GI series until obstruction is ruled out.)
 Dehydration – unlikely, moist and pink nose and throat, normal skin
turgor. Rule out with blood urea nitrogen/creatinine ratio of less than 20:1
 GERD – ruled out, discomfort and bloating is constant, not intermittent
and not consistently related to food. No patient hx, no family hx
 Urinary tract infection – ruled out by results of in office urinalysis which
was normal. No WBCs present.
Plan:
Diagnosis:
Constipation
Diagnosis studies:
 Abdominal x-ray
Diagnostics labs:
 Electrolyte profile to evaluate electrolyte and fluid status
Pharmacology:
 Fleet mineral oil enema:100 ml PR one time
 Psyllium (Metamucil), 1 packet in 8 oz liquid. Start with 1
dose per day, gradually increase to minimize gas and bloating
Education/Counseling:
 Explanation of each diagnostic procedure and its purpose

 Lab work and how they apply to patient’s condition
Health Promotion/Anticipatory Guidance:
 Dietary for foods and fluids that support bowel health
 Can introduce prune juice to diet
 Continue her exercise regimen as tolerated
Differential Diagnoses:
Diverticulitis
Diagnosis studies:
 Abdominal x-ray
Diagnostics labs:
 CBC to check WBCs
Pharmacology:
 To be determined by diagnostic results
Bowel Obstruction
Diagnosis studies:
 Abdominal x-ray
Diagnostics labs:
 CBC to check WBCs
Pharmacology:
Dehydration
Diagnostics labs:
 Electrolyte profile to evaluate electrolyte and fluid status
 BUN: rule out dehydration with blood urea nitrogen/creatinine
ratio of less than 20:1
Pharmacology:
 Fluid intake for proper hydration
Referrals:
 Proctology if no recent history of colonoscopy
Follow-up:
 One week for evaluation of relief of constipation
 Two weeks for diagnostic test result evaluation
Self-Assessment:
Ms. Park was easy to interview. An adequate health history and physical
examination was performed. The assessment involved all pertinent systems. I ordered a
simple abdominal x-ray study as the least expensive option to confirm the diagnosis and
rule out differentials. CT scan can be ordered if needed based on preliminary test results.
References:
Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M., (2017). Bates' guide to physical
examination and history taking. (Twelfth ed.) Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Goolsby, M., & Grubbs, L., (2019). Advanced assessment: Interpreting findings and
formulating differential diagnosis. (Fourth ed.) Philadelphia: F. A. Davis
Rhoads, J., & Petersen, S. W. (2017). Advanced health assessment and diagnostic
reasoning (Third ed.). Sudbury: Jones & Bartlett Learning, LLC.

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What symptoms led the patient to seek medical attention?

What are the differential diagnoses considered for the patient's condition?

Myrnaivette Pierson Focus Note

Date of encounter: April 15, 2019

Personal and Social History:

Pertinent Review of systems:

 Explanation of each diagnostic procedure and its purpose

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